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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416153
Report Date: 11/20/2024
Date Signed: 11/20/2024 12:11:04 PM

Document Has Been Signed on 11/20/2024 12:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:LI, ZHIQINFACILITY NUMBER:
434416153
ADMINISTRATOR/
DIRECTOR:		ZHIQIN LIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 718-1201
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 14TOTAL ENROLLED CHILDREN: 4CENSUS: 4DATE:
11/20/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Zhiqin LiTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Fermin Campos-Jaramillo and Kate Huang met with licensee Zhiqin Li in a case management inspection. At arrival licensee was providing care to one infant, later arrived two more infants and one preschool age child. Licensee stated she currently does not have a helper. LPA observed the home has at least one working fire extinguisher and smoke and carbon monoxide detectors, and barricaded stairs. Licensee's pediatric CPR and first aid card is current and will expire on 5/06/2025.

During the inspection one type A and two type B deficiencies were cited.

LPAs discussed the requirements of AB633 to licensee. LPAs provided her the AB633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and licensee stated she understands the requirements. Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

Failure to comply with the Plan Of Corrections (POC) by the due date on LIC809D shall result in an immediate civil penalty of $100 per day per each deficiency.

A notice of site visit was given and must remain posted for 30 days

SUPERVISORS NAME: Susy Cervantes
LICENSING EVALUATOR NAME: Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 11/20/2024 12:11 PM - It Cannot Be Edited


Created By: Fermin Campos-Jaramillo On 11/20/2024 at 10:54 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: LI, ZHIQIN
FACILITY NUMBER: 434416153

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/21/2024
Section Cited
CCR
102425(h)

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102425 (h) Car seats shall only be used for transportation purposes and shall not be used for sleeping. This requirement was not met as evidenced by”
Licensee stated that she has left infants sleeping in a car seat for up to 20 minutes, this Poses an immediate risk to the health, safety or Personal rights to children in care.
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Licensee shall submit an statement to Licensing Program not later than 11/21/24 close of business, stating that she understands safe sleep regulations. Licensee was also instructed on the AB633 regulations.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Susy Cervantes
LICENSING EVALUATOR NAME:Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/20/2024 12:11 PM - It Cannot Be Edited


Created By: Fermin Campos-Jaramillo On 11/20/2024 at 11:07 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: LI, ZHIQIN
FACILITY NUMBER: 434416153

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/04/2024
Section Cited
CCR
102425(c)

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An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age. This requirement was not met as evidenced by: Licensee was unable to produce a form Lic9227 for infant ch #nth of age the provider has in care and maintained at the facility in the infant’s file. 1.
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Licensee shall complete a Lic9227 (provided to licensee) for ch # 1 and submit a copy to Licensing Program no later than 12/04/24.
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this poses a potential risk health, safety, personal rights risk to children in care.
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Type B
12/04/2024
Section Cited
CCR102425(j)(1-2)

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(1) The provider shall physically check on the infant every 15 minutes. (2) The provider shall check and document the following: (A) Labored breathing.
(B) Signs of distress which includes but is not limited to flushed skin color, increase in body temperature and restlessness.
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Licensee shall immediately start documenting the sleep of children under two years old. Licensee will submit a copy of the log (provided) no later than December 4, 2024 for the period 11/20/24 to 12/03/24.
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This requirement was not met as evidenced by: Licensee was unable to produce a safe sleep log for the infants in care, this poses a potential risk health, safety, personal rights risk to children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Susy Cervantes
LICENSING EVALUATOR NAME:Fermin Campos-Jaramillo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2024


LIC809 (FAS) - (06/04)
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